Alcohol use typically begins in the adolescence and peaks over the adulthood. However, its abuse is not as uncommon among the elderly though it tends to be under.recognized. Certain age.related physiologic, biologic, and psychosocial issues pose unique challenges in the diagnosis as well as management of alcohol use disorders in the elderly. Indian studies. .. specifically focusing on elderly substance users. .. are few. Screening should be a crucial component during clinical encounters with elderly populations across a variety of settings. Depending on the extent, nature and pattern of use, the elderly persons may need less intensive, brief interventions to more intensive inpatient care for safety concerns. Emphasis should always be on age.specific treatments delivered by trained personnel using nonconfrontational approaches.

Keywords: Alcohol, elderly, substance use

How to cite this article:Lal R, Pattanayak RD. Alcohol use among the elderly: Issues and considerations. J Geriatr Ment Health 2017;4:4-10

Substance use, including alcohol, typically begins in the adolescence and continues or peaks through the adulthood often with a remitting and relapsing course. Consequently, a large proportion of the clinical and research attention is directed toward younger and adult age groups, leaving the elderly with substance use problems a relatively neglected subgroup.[1] The substance use from an earlier age may continue into later life making it more chronic and complicated. Occasionally, the onset of substance use/misuse maybe in old age. Further, aging-related medical conditions make the older substance users a vulnerable group for harmful consequences.[2]

From a public health perspective, the demographic aging is now a global phenomenon.[3] This demographic transition is unprecedented and likely to continue in the future. Between 12% and 16% of the population in most Western countries and about 8% of the Indian population is above 60 years.[4],[5] with a globally projected increase up to 20% by the year 2050. This “graying” of population bears tremendous health implications, especially for developing countries. Therefore, there is an emerging need to pay greater attention to elderly mental health as well as substance use problems.

The paper aims to discuss the elderly alcohol use, including the extent and pattern of use, barriers to treatment, sociocultural factors, screening, and management considerations in this sub-population.

Elderly Alcohol Use: A hidden Problem

From the available studies on adults, the trends show a decreasing consumption with increasing age, which may possibly be attributed to an aging effect (i.e., drinking less due to physiological effects), cohort effect (i.e., older cohorts may consume differential or less alcohol), or the mortality hypothesis (i.e., heavy users may die younger).[6] However, the same has been challenged in the more recent studies. Studies from medical settings have shown about 10%–15% of older adults in the primary care settings and as many as 30% of hospitalized adults in general medicine have alcohol and drug use problems.[7],[8] Unfortunately, a majority of these older adults remain undetected.

In clinical interactions, the specific exploration for the use of alcohol or drugs is often not done in elderly patients, leading to underrecognition of geriatric substance use. Physicians, themselves, often fail to adequately screen for the geriatric substance abuse for several reasons,[1],[9] as follows:

Lack of awareness and sensitization about the problem; stereotypical view of alcohol abuse as a phenomenon of the youth

Inhibition or embarrassment over screening for alcohol abuse from a senior citizen

Failure to link the coexisting medical problems with a possibility of underlying substance abuse and attributing it instead to aging. For example, alcohol use may present as insomnia, confused states, which may be linked to the aging process

Therapeutic nihilism about the elderly alcohol and drug use (e.g., even if he is using, then what is the point of intervening? It is okay for him to use)

Widespread use of prescription medications for the comorbidities among elderly hinders the detection of abuse.

Further, it may not come to clinical attention for a variety of other reasons, for example, underreporting by the patient or lack of informant/staying alone. Many elderly people do not disclose information about their drinking because they be ashamed of doing so at their age. Many are isolated from their family members, with minimal social networks, thereby making the problem even more difficult to detect.[10] Often, the underlying alcohol use may be “discovered” per chance in relation to consultations sought for other medical or health problems. Elderly patients may be less strongly motivated to change their drinking. For some older adults, a foreshortened sense of future may further inhibit motivation to reduce alcohol use. In addition, self-efficacy to reduce drinking may decline with age, with a lower perceived control over his or her life, especially in the event of stressful life events.

The elderly form only a very small proportion of service users for addiction services. This can be partially attributed to elderly facing more “barriers” to access the services, including dependency on others, relatively limited mobility due to chronic medical problems, stigma, and logistic aspects, thereby remaining an invisible population.[2],[11]

Issues Specific to Older Age

The pharmacokinetic and pharmacodynamic aspects differ in the elderly patients. In case of elderly, alcohol attains higher blood levels due to a decrease in body water and body mass with age, and a decreased rate of metabolism. Consequently, it accumulates in the body leading to intoxication even with lower amounts of intake. Further, the sensitivity to alcohol increases since the tolerance decreases with age. Older adults are, therefore, more vulnerable to the physiological effects of alcohol than younger adults.[2],[10] As alcohol produces higher and longer-lasting blood alcohol levels in older adults compared to younger people, many problems such as chronic illnesses and poor nutrition may be exacerbated by relatively smaller amounts of alcohol. The use of alcohol or drugs is also potentially more harmful in the elderly due to preexisting cardiac and hepatic problems, a compromised immune system, more vulnerability to complications, etc. Certain illnesses such as hypertension and diabetes might worsen with chronic alcohol use, and the medications used to control these conditions may have drug-drug interactions with alcohol. Older adults are also more likely to have been prescribed medications for comorbid illnesses, which puts them at risk of potential harm in terms of drug-drug interactions. The drug-drug interactions may include increased blood alcohol levels, alterations in drug metabolism, disulfiram-like reactions (e.g., coadministration with certain antibiotics, nitrates,), cumulative adverse effects, and interference with the effectiveness of prescribed medications.[12] The physical reserves in old age are impaired, and they may already have preexisting cognitive impairments and motor incoordination.[2],[10],[13]

Unlike younger substance abusers, the elderly patients are more likely to have medical complications of alcohol use. The use of any psychoactive drug is directly or indirectly related to a significant increase in the risk of hip fractures in this age group. Alcohol is more likely to cause gastroesophageal reflux, hepatic damage, neurological impairments, Wernicke–Korsakoff syndrome, etc., in the elderly. Chronic alcohol use may exacerbate hypertension and hyperlipidemia and mask angina pectoris, raising the cardiovascular risk and mortality.[10],[13],[14] In terms of gender differences, women are at an even higher risk for negative physical and psychological consequences associated with alcohol consumption. Older women may have several additional biologic and psychological vulnerabilities, such as menopause and empty nest.[15]

It is also well established that the elderly alcohol and drug users have high rate of psychiatric comorbidity and psychosocial stressors, which need to be attended to. Alcohol using elderly may have underlying emotional or psychological symptoms, depressive symptoms and even, alcohol use has been associated with increased risk of suicide among older age groups. Treating physicians or family members may rationalize the older person's alcohol abuse, especially if this is consequent to a loss or bereavement. However, all efforts need to be made to detect any underlying mood or anxiety disorders. Older adults may benefit from psychiatric interventions in the form of direct health benefits of abstinence, improved cognition, more independent living, and better social connectedness.[16]

Sociocultural Aspects: Aging, Mental Health, and Alcohol

In traditional India, elderly are a revered member of the family, often head the families and continue to make important household decisions (from matrimonial alliances to community development to conflict resolution). Elders invest their time with grandchildren and contribute to societal matters. In the ancient Indian texts, most sages have advised to follow an element of detachment from worldly pleasures and pursuits (māyā) with a more contemplative life during old age.

With changing societal norms in recent decades, there has been a gradual decline of extended family systems due to various factors, for example, urbanization, migration, female workforce participation, and changes in cultural values and beliefs. A gradual shift toward individualism and materialistic culture has led to the alienation of elderly. The unconditional authority of elderly is gradually being affected by a multitude of these changes. All these factors have led to a more changing role of elderly compared to earlier generations, which may often lead to familial and interpersonal conflicts, leading to isolation and psychological ill-health of elderly.[17],[18]

Old age is heralded by several life events in the form of retirement from active work, medical illnesses, etc. There may be stressful life events, for example, widowhood, which may lead to increase in alcohol use. As there is no active work life, the dysfunction pertaining to alcohol use may not be as apparent in the initial stages. Alcohol, being a licit substances, is accepted to a certain extent as per the societal norms. Alcohol use may be normalized in the older adults, often considered as “one of the few indulgences” or “pleasures” sought at that age. These social, cultural, and aging-related factors may influence the extent and pattern of use of alcohol as well as the clinical presentation and readiness to engage with services.

Epidemiology and Risk Factors

Indian data

Specific studies focusing on elderly substance use are relatively infrequent in India. [Table 1] lists the recent large-scale surveys which have included the prevalence of alcohol use or alcohol use disorders in elderly age groups.,[19],[20],[21],[22],[23] of which two had been planned as geriatric psychiatric community surveys,[19],[20] two were general/health-related surveys,[21],[22] but included some information on alcohol use among the elderly age group, and one was prevalence among elderly patients visiting a tertiary care hospital mental health services.[23] The methodological aspects and key findings from these surveys have been summarized in [Table 1].

In another large-scale population study, the current use of alcohol (any use in the past 1 month) varied between 10% and 28% among 50 years plus age groups, majority being current heavy users.[24]

In a clinic-based review of elderly patients presenting for treatment, alcohol (60%) and opioids (35%) were commonly misused substances.[25]

In a recent review of Indian literature specifically for alcohol use in older adults, a total of 31 articles were selected, inclusive of small scale, regional, and larger surveys.[26] It was observed that there was a dearth of pan-national studies. In general, studies do indicate that a substantial proportion of individuals above the age of 50 years are current consumers of alcohol, and the prevalence is generally higher in urban compared to rural areas. Older women are generally likely to be alcohol abstainers.

Available research review indicates that the substance abuse in elderly is highly correlated with the presence of depression.[18] Individuals over 60 years presenting with substance use should, therefore, be routinely screened for depressive symptoms.

International data

A review of Indexed literature base (year 2000 onward) identified 21 peer-reviewed publications and six reports, including data from 17 national surveys and 10 general practice and community samples.[27] Findings reveal that the rates of past 12-month abstention varied widely between developed countries. For example, among adults aged 65 years and older, the abstention was higher in the US (63.2% men and 81.0% women) in contrast to the UK (15% men and 27% women) and rest of Europe. The prevalence of excessive weekly and daily drinking was consistently lower among women than men in all countries. The rates of alcohol dependence were, however, broadly similar and were found to be nearly 0.4% in the US to 3% in Brazil and the UK.[27]

The 2013 National Survey on Drug Use and Health found heavy drinking (defined as drinking 5 or more drinks on the same occasion on each of 5 or more days in the past 30 days) among 4.7% of 60-64-year-old, and 2.1% of those over age 65.[28] Among community, noninstitutionalized adults aged 50 and above years, about 60% had used alcohol, 3% had used illicit drugs, and 1%–2% had used nonmedical prescription drugs in the past year.[16]

Although available research shows that a larger percentage of elderly men compared to women engage in alcohol use, women are more likely than men to start drinking heavily later in life.[15],[27],[28]

Pattern of Use in Elderly

Although two-third of alcohol use disorders have an early adult onset as many as one-third also had onset of alcohol use later on in their age. This late-onset category first develops the drinking problems at 40–50 years of age. In contrast to early-onset group, they tend to be more educated, have a stressful life event frequently precipitates or exacerbates their drinking, and tend to be better responsive to treatment.[1],[10],[27]

Elderly alcohol users are more likely to have “at-risk drinking” compared to the prevalence of alcohol abuse or alcohol dependence.[10] This at-risk drinking puts them at risk of physical harm to the health and well-being. Guidelines by the National Institute for Alcohol Abuse and Alcoholism recommend that older adults drink no more than 7 standard drinks per week. However, about 16% older-adult do engage in at-risk drinking (defined as more than 3 drinks on one occasion or more than 7 drinks per week).[29] In addition, binge drinking may also occur in a substantial proportion of the older-adult population. Alcohol-dependent use is also present in a relatively smaller but significant subset of elderly patients using alcohol.

Older patients are more relatively likely to abuse licit substances, commonly alcohol, tobacco and also, over the counter medications. The misuse of prescription medications may be seen concurrently to alcohol use. Up to 25% of all over-the-counter medications are consumed by the elderly, and it is estimated that abuse of prescription medicines may double from 1.2% currently to 2.4% by the year 2020.,[30] making it pertinent to screen not only for alcohol but also for possible co-occurring use of other prescription drugs.

Screening

To begin with, the use of alcohol must be suspected in older adults as well, especially in consultations for medical issues which could be related - directly or indirectly - to alcohol use. Every individual over 60 years of age should be screened by asking a series of relevant questions probing the use of substances, especially if s/he has any of the risk factors evident from the history (e.g., insomnia, drug-seeking behavior, etc.).

Alcohol misuse can be screened using simple, easy to use screening tools, which have been validated for the geriatric population. These have been summarized as follows.[2],[10]

CAGE-Adapted to Include Drugs (CAGE-AID)

It has been validated for use to screen for alcohol in older-adult population, demonstrating 86% sensitivity and 78% specificity for a score of one or more.[31],[32] The questions can be adapted to a different substance, such as a prescription medication. It has been adapted, though not yet validated, to also assess for drugs by modifying the questions, as follows:

Have you ever felt that you should cut down on your drinking or drug use?

Have people annoyed you by criticizing your drinking or drug use?

Have you ever felt bad or guilty about your drinking or drug use?

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

It is to be noted that CAGE does not distinguish between current and lifetime use, where elderly may often have a history of problematic use without any current problem.

The Alcohol Use Disorders Identification Test

This 10-item questionnaire has been widely used in literature. The recommended cutoff score for the Alcohol Use Disorders Identification Test (AUDIT) typically is 8; however, it has been suggested that for older adults, a score of 5 should alert the clinician. Five items on the AUDIT (items 1, 2, 4, 5, and 10) are particularly important for older adults.[33]

The Michigan Alcohol Screening Test-Geriatric Version

Researchers at the University of Michigan have developed the Michigan Alcoholism Screening Test – Geriatric Version (MAST-G) and the shorter version, the Short MAST – Geriatric Version to screen the older adults in a variety of settings. Because of the diagnostic challenges posed by elderly substance use, the MAST-G focuses more on potential stressors and behaviors relevant to alcohol use in later life, as opposed to routine questions toward vocational, and legal consequences of use.[34]

The Comorbidity-Alcohol Risk Evaluation Tool

It is a screening instrument which identifies at-risk older adults taking into account their quantity and frequency of alcohol use, presence of comorbid disorders, high-risk behaviors and concomitant use of other medications, with a good face, content, and criterion validity in older adults.[35]

In addition, there are two self-report instruments, namely, the Alcohol-Related Problems Survey (ARPS) and its shorter version the Short ARPS (shARPS), which have been compared against the longitudinal evaluation done by experts employing all available data (LEAD). The sensitivity and specificity of the ARPS and the shARPS as compared to the LEAD were 93% and 63%, and 92% and 51%, respectively. Harmful and hazardous drinkers were most often identified because of alcohol use with comorbidities, symptoms, and medication use.[36]

Diagnostic issues

The current system of psychiatric classifications uses the same criteria for the diagnosis of substance use disorders across all age groups. There is some suggestion from existing literature that the certain features in diagnostic criteria such as drunken driving arrests, neglect of child care, or work-related issues may not be as relevant for the elderly. This may present technical challenges for making the diagnosis of substance use disorders among older adults. Further, it is also known that elderly generally experience a reduction of physiological tolerance to these substances, thereby impacting one of the key criteria (increased tolerance over time) for making the diagnosis.[10]

Research has also shown that older adults were half as likely as middle-aged adults to endorse the criteria related to tolerance, activities to obtain alcohol, social/interpersonal problems, and physically hazardous situations. The diagnostic criteria that could reliably discriminate alcohol use disorder among older adults were (a) unsuccessful efforts to cut back, (b) withdrawal, and (c) social and interpersonal problems.[37]

Management of Elderly Alcohol Use: Approach and Considerations

There are several misconceptions regarding the treatment of alcohol use in older adults, including the belief that older adults are not as responsive to treatment. A 30-year review of alcohol use treatment in older adults found comparable rates of abstinence with the general population.[38] There is no reason to be less optimistic on the part of the treating physician as far as the efficacy of treatment is concerned although caution should be exercised for safety concerns.

The setting (outpatient versus in-patient) has to be determined by the treating psychiatrist at the outset. In the elderly age groups, there may be comorbidities such as diabetes or uncontrolled hypertension, or cardiovascular disease, collaboration with other medical specialties which may warrant an inpatient stay for a closer monitoring. Further, in the event of elderly staying alone and possible underreporting of the amount of alcohol consumed, it is better to monitor him more closely during the withdrawal phase. Usually, elderly with associated psychosocial issues and psychiatric comorbidities are also candidates for more intensive interventions, including psychosocial interventions.

For elderly with occasional or nondependent alcohol use, pharmacotherapy has a relatively limited role; emphasis should always be on psychoeducation and brief psychosocial interventions with a careful risk-benefit analysis for more intensive/pharmacological treatments. The least intensive treatment options should be explored first with older substance abusers. Brief intervention (BI) is the recommended first step, followed, if necessary, by other more specialized interventions

For elderly patients who are moderate to heavy/dependent users are likely to have medical and psychological comorbidities, an initial inpatient care for comprehensive assessment and management of complications, if any, might be warranted in many cases. An inpatient treatment is even more important if social and family support is inadequate. Nutritional status, fluid, and electrolyte imbalances need attention on a priority basis.

Pharmacotherapeutic options

The pharmacotherapy is preferred an option for short-term control of withdrawals, treatment of co-occurring medical/psychiatric conditions (if any) and occasionally, whenever suitable, for long-term treatment of alcohol use disorders. Pharmacological treatments must always be given on principle of “start low, go slow” along with an intensive monitoring for early detection of adverse effects, which may include cognitive impairment, hypotension, and falls.[10],[38] Elderly patients are particularly susceptible to the onset of some complications associated with heavy alcohol use, such as Wernicke–Korsakoff syndrome, for which thiamine supplementation should be given in all elderly alcohol users.[8]

For short-term treatment aimed at the management of withdrawal, the use of long-acting benzodiazepines (e.g., diazepam, etc.) must be avoided in the elderly population as the long-acting agents are slowly cleared due to reduced hepatic clearance with age, which may be associated with undesirable adverse effects in the form of excessive sedation or motor in coordination. Lorazepam (4–12 mg/day, titration depending on various clinical factors) may be a safer alternative in case of elderly patients. Careful charting of vitals, withdrawal symptoms and signs must be done on a periodic basis in addition to monitoring for relevant medical parameters for comorbidities. A gradual taper is done for lorazepam over next 7–10 days, depending on patient's comfort and withdrawals. As a rule, the tapering regimen must always be discussed with patient and daytime doses may be tapered off first.

As far as long-term management of alcohol use disorders is concerned, the pharmacotherapy is available in the form of deterrent agents (disulfiram) and anti-craving agents (Acamprosate, Naltrexone). As far as elderly population is concerned, there are certain precautions and extreme caution needs to be exercised while prescribing the medication, especially disulfiram to older adults. Disulfiram should not be started if there is underlying hepatic dysfunction or if serum glutamic oxaloacetic transaminase/serum glutamic-pyruvic transaminase are raised twice or thrice above normal. At the time of initiation, one has to ascertain; there is no alcohol use in the preceding at least 12 h. Disulfiram therapy works best if dosing is supervised by a family member to ensure compliance. This may be again a problem with elderly, who may not have adequate social support or whose family members may not have time for supervision or accompany for follow-up. Elderly may often have subtle, age-related cognitive impairments. Further, if there is a risk of ongoing or intermittent alcohol use while on disulfiram, the elderly may experience serious complications, especially if staying alone. Disulfiram is contraindicated in patients with a history of seizures or psychosis, cerebrovascular disease, peripheral neuropathy, etc., which may be otherwise common comorbidities among elderly patients. The use of disulfiram, therefore, may be done only with extreme caution in elderly alcohol users.[8],[38]

Naltrexone blocks the effects of endogenous opioids and prevents the dopamine release resulting from alcohol consumption. It reduces the reinforcing effects of alcohol, which may lead to reduction of alcohol-seeking behaviors and cravings. Naltrexone (50 mg/day) may be used as a harm reduction approach to reduce the quantity of alcohol consumed by an individual. Naltrexone can also cause hepatotoxicity in higher doses; hence, it is to be avoided in elderly patients who have hepatic dysfunction, such as hepatitis or cirrhosis. Liver function tests should be done before initiation of naltrexone and regularly every 3 months thereafter. A major limitation of naltrexone in the elderly population, especially those with prominent, chronic pain, is that it blocks the effect of opiate-based analgesics. It can potentiate preexisting major depressive disorder symptoms, which will require a close monitoring. Patients with histories of comorbid depression should be closely monitored.

In a randomized controlled trial (RCT), among the individuals exposed to alcohol, older adults on naltrexone were significantly less likely to relapse than those on placebo.[39] In another randomized controlled study, older adults demonstrated significantly greater rates of treatment engagement and medication adherence than the younger adults. This is contrary to the popular belief that elderly substance users may be difficult to engage population with poorer outcomes.[39],[40]

Acamprosate (doses up to 2 g/day in divided doses; available as 333 mg tablet) is a relatively safe medication aimed at the reduction of craving for alcohol. It works by decreasing the craving for alcohol through a yet unclear mechanism of action, and it may be prescribed for persons with mild to moderate liver dysfunction (in view of its predominantly renal clearance) though avoided in cirrhosis and severe hepatic decompensation. It is, however, contraindicated in patients with renal insufficiency. The frequent dosing may be perceived as somewhat problematic.

In terms of research studies, in general, there is a dearth of randomized studies/RCTs testing the efficacy of long-term pharmacotherapeutic agents among the older adult population.

Psychological Interventions for Elderly Alcohol Users

In elderly with new onset, short term, and mild to moderate alcohol consumption, the pharmacotherapy has a relatively limited role, and one may choose to focus primarily on psychosocial interventions, including supportive therapy, motivation enhancement therapies cognitive behavioral therapies, activity scheduling, and lifestyle changes.

Elder-specific treatments need to be relevant and acceptable both in terms of content (e.g., to cope with the challenges associated with late life stages, such as retirement from active work, widowhood, “sense of foreshortened future,” etc.), as well as in terms of processes (e.g., nonjudgmental, nonconfrontational therapeutic style, delivery taking into account the reduced psychomotor speed, etc.).

Nonpharmacological treatment may include psychosocial support, involvement in self-help and support groups comprising other elderly with similar problems.[7],[8],[9],[10] In the Indian context, families are an important source of care and caregiving for elders, and should always be involved in the treatment of substance use disorders.

In general, the following components have been recommended to be incorporated to enhance the treatment outcomes:[41],[42]

Emphasis on age-specific/age-relevant treatment approaches

Use of supportive, nonconfrontational approaches than more assertive styles of assessment, and intervention

Focus on cognitive-behavioral approaches

Development of skills for improving social support

Recruitment of personnel trained to work with older adults

Use of age-appropriate pace and content.

A continuum of psychological interventions is available for elderly alcohol users, depending on severity of the problems. The BIs are less time-intensive and can be easily provided in busy medical settings. Their purpose is to provide a feedback of the potential harm, education about the substance, enhance motivation for change, and offer a range of options for treatments to the users, as relevant. Most BIs may be carried out with principles of motivational interviewing or motivational enhancement therapy, which encourages a client-centered, nonjudgmental approach to encourage healthy changes to the individual's life. For the elderly, the reasons for making such a decision for change may include maintaining their physical health status, psychosocial independence, and minimizing the potential adverse impact of alcohol on cognition. The BIs may be provided by a variety of trained health professionals with whom elderly may come in contact for medical reasons, making it a cost-effective approach from a public health perspective.[41]

As the accessibility to services and unaided mobility is often an issue with elderly patients, some researchers have attempted to develop mobile health interventions for older adults with alcohol problematic use. Mobile health interventions could increase access to the health-care system who might otherwise avoid treatment due to stigma or isolation. This has the added benefit of being inexpensive and may be used for relapse prevention interventions.[43]

Future Directions

In future, there is a need for more active efforts directed toward developing effective screening methods to screen for elderly substance use in India. Another major need is the development of culture-relevant and age-adapted psychological interventions, which may be more acceptable to the elderly age groups. In terms of drug efficacy, there is also a need for more randomized studies/RCTs testing the efficacy of long-term pharmacotherapeutic agents among the older adult population.

Future directions in research should address the lack of age-appropriate assessment instruments and the underrepresentation of gender-related issues in elderly substance use research. The large scale training and sensitization of the general physicians, geriatricians, and health-care workers need to be done for the availability of services “closer to the doorstep,” and various policy level efforts at service provision and integration with medical care need to be made.

Conclusion

Alcohol use is not uncommon among the elderly; however, it often remains under-recognized and is commonly associated with physical and psychological comorbidities. The pattern of use may vary widely from less occasional use to problematic to even a dependent use, however, elderly are more vulnerable to the physiologic effects and medical complications of alcohol use. Certain age-specific issues may need careful consideration. Screening should be a crucial component during clinical encounters with elderly populations across a variety of medical settings. Depending on the extent and pattern of use, the elderly persons may need less intensive treatments, relying mainly on BIs, and psychosocial support, especially for occasional/nondependent users. When pharmacotherapy is used, it needs to be tailored to the needs of the individual, including the presence of comorbidity and slower metabolic rates. The treatment outcomes appear to be similar to adult populations. Emphasis should always be on age-specific or age-relevant treatments delivered by trained personnel using nonconfrontational approaches.

United Nations. World Population Prospects: The 2010 Revision (Washington, DC: Population Division, Department of Economic and Social Affairs, United Nations). Available from: http://www.esa.un.org/wpp/. [Last accessed on 2013 Jan 30].